This interview was made on April 4, 2020 and portions of it will be broadcast by the WBAI radio station in New York City on April 15, 2020 in the course of the AfroBeat weekly program hosted by Wuyi Jacobs, in the section reserved for community affairs.
Editor’s note: Often when thinking of health services in Italy, there is a widespread belief abroad that we are talking about a centralized National Health System, which did exist up to the 1990’s. In reality, over the past 30 years, the health system has gradually become decentralized and placed into the hands of the regional administrations. Due to neo-liberal policies and austerity measures dictated by the EU, much of the system has been cut back and dismantled, favoring the growth of private sector health providers. The pitfalls and limitations of this for-profit new system has been revealed in this latest pandemic, especially in Lombardy, though that had been touted as a model to be followed. For more information related to regional administration of Lombardy, see https://en.wikipedia.org/wiki/Roberto_Formigoni and today’s Lega’s governorship by Attilio Fontana https://en.wikipedia.org/wiki/Attilio_Fontana, since 2018.
- Please introduce yourself and give us a brief description of the different phases you and other health workers have gone through from end of February to now, especially given that your city is located at the center of the epidemic.
My name is Valeria Raimondi, I live in Brescia, one of the largest cities in Lombardy and among the most affected by the Covid-19 pandemic. I am 56 years old and have been working as a nurse for 40 years in the hospitals of this province. I also am a writer and a poet, as well as an activist for workers’ and immigrants’ rights, the environment and other movements. As a nurse, I have been directly involved in this Covid-19 emergency since the end of February, as part of my work in the facilities of the National Health System, under Regional administration which includes some of the hospitals that are at the epicenter of the infection, that is, in the area between Garda lake and the province of Cremona, right in the center of the Po valley. The emergency progressively involved the provinces of Lodi, Cremona, Bergamo and Brescia, the latter two being the ones that have currently the highest numbers of active cases and deaths. Since the end of February everything has changed in our workplaces. There was a rapid evolution. There wasn’t an actual pandemic plan, and if there was one, we certainly didn’t see it. The hospitals implemented the early stages of distancing and isolation, the first PPEs were introduced (I will expand on this later), and the first frantic responses were given to the ordinances issued by the central government and the regional administration, which ordered the closures, re-opening and again closure of services. Then, the first organizing of wards began. However, it was never decided that the ER should not accept people showing flu-like symptoms or pneumonias. And perhaps this acted as a fuse that ignited the spread of the infection… In the meantime, the seriousness of the situation became increasingly obvious and, thus, we experienced the first bottlenecks in the ERs and their Brief Intensive Observation units. Besides the usual patient volumes, the bottlenecks were caused by the high volume of patients with symptoms who were parked there waiting to either be discharged or hospitalized in the wards of the hospitals where the ER was located or transferred to others. The hospitals needed to get prepared, but they had a reduced number of staff due to earlier cuts that had been made before this emergency.
2) Please describe your workplace at the hospital in Brescia. How have things changed compared to your regular workload?
Things have changed mainly as far as two aspects are concerned: the way the work was organized and the constant uncertainty due to the emergency. This Covid-19 situation seems to have found the hospitals unprepared, and day by day procedures and protocols were changed based on choices made by the Lombardy regional administration (often choices that were not consistent with decrees issued by the central government or the practices of other regions). Of course, what happens inside a hospital reflects the confusion of what is happening outside as well. There had to be changes in scheduled shifts, which before had been planned on a monthly or a weekly basis and now were planned on a daily basis. Days off were canceled and vacation time for personnel has been suspended since early March. Overtime increased way beyond regular times. From my position, I could observe changes even in the daily routines, as oncology, cardiovascular, chronic patients and trauma victims and surgical emergencies still needed to be attended to and continued to have their pressing needs! Dialysis or physical therapy or life-saving procedures cannot be halted. But access to care became riskier and more difficult even for these patients requiring urgent attention. Thus, health personnel at all levels, even if not on the frontlines of Covid-19, became aware of the consequences of the epidemic: women who were to give birth could not have their partners with them because since mid-March relatives or assistants could not be admitted into a hospital with the patient. The same is true for oncological patients. Of course, relatives were very worried as they could not visit their family members, as all visits for hospitalized patients were forbidden. The situation was dramatic for everyone working in ER, in Intensive Therapies or in Reanimation. The daily work hours increased and continues to increase out of proportion, the staff was and continues to be exhausted, a sense of powerlessness and psychological pressure overcame us as well as rage… at times. (the idea being that you don’t have to become a martyr in order to a hero!) What happens is that Intensive therapy and Isolation wards become way overcrowded, while the numbers of health staff continuously decrease because they get sick or infected. We’ll see why this happens.
3) Can you talk about the situation of health workers in general in the region? Are there enough protective devices? How can one account for the death of over 100 health providers?
The history of the Public Health System run by the Regional administration is fairly well-known here in Italy, but what is less known is the situation of those who work within it. The dismantling of the state run health system to the advantage of the private sector by depleting the public facilities has meant less protection for all, differences in salaries even for those performing the same job and with the same qualifications, reduction in hospital beds and capacity with increasingly heavier loads, the piling up of overtime which is not paid as such, the halting of contract renewals for public employees, blocks on permanent hiring or temporary hiring (staff hired under emergency calls today are not considered permanent hires). In addition, deals between the public and private sectors have endangered work positions, have resulted in cuts in services and personnel, no new hiring competitions (in Italy positions in the public sector are still done through nationwide competitions organized by the State) and no hiring. Within this compromised picture, now we must face a new reality: health and safety in the workplace can no longer be ensured. With Law n. 81 of 2008, a definition of the concept of prevention and protection was instituted, distinguishing between various risks and there was to be an implementation phase was set for equipping different types of personnel with personal protection devices. But obviously there was a lack of foresight, as those in charge failed to provide hospitals with the adequate and sufficient gear. The problem of safety gear was the first one to present itself in this crisis. Both in terms of their scarcity and inadequacy. At least in Lombardy, the issue of scarcity became immediately apparent as far as protective masks are concerned. The supply available could cover only normal situations and not extraordinary ones like Covid-19 pandemic. But there’s also another problem, there wasn’t a unified protocol of intervention. It was immediately understood that there was a scarcity of masks in classes that were higher than ffp2 and ffp3, which initially were defined as the correct ones for assistance in epidemics of viral infections. But the instructions issued by the Ministry of Health and Welfare of the Lombardy region changed day by day and became more complicated. The distancing measures defined one meter as sufficient to avoid direct contact and, thus, the rule for advanced gear no longer applied (even in isolated rooms with positive patients sometimes). And it’s allowed only for specific manoeuvres in reanimation wards. But there are many manoeuvres that imply risk, and keeping distances in the process of assistance is not always possible! Finally, only a few days ago new protocols were put in place contemplating the ‘possible’ use of advanced masks. The paradox is that we perform services to patients who wear an ffp3 mask while the staff wears a surgical one – and it should be the other way around! In my opinion this is the first cause for the massive spread of the virus among health personnel. As a result, there’s the problem with the swabs as the most favored test to diagnose the virus. Another directive issued four weeks ago establishes that these swabs, from now on, are no longer to be performed on all health personnel who have assisted or had contact with sick patients, or those who were found to be positive to Covid-19, but testing is reserved only to those who show symptoms. However, testing and quarantine continue to be guaranteed, if I’m not wrong, to sports figures, politicians and other people who are privileged. Starting last week, though, after the protests of workers and unions, some of the facilities have an area reserved for personnel at work (but only their hired personnel) that measures body temperature, which is defined to be acceptable if under 37.5 degrees Celsius and the person is considered “asymptomatic”. And they call this prevention. This is one of the reasons why there has been an exponential growth in the number of health personnel who have gotten sick and unfortunately some of them have died. The disaster took place in the hospitals and it’s the result of it. The places that were supposed to ensure care unfortunately became too often the place of contagion for patients and medical personnel.
4) Can you please talk about the cuts in public health spending by the State, privatizations and how the right-wing regional government has affected it all? Have similar things occurred in other regions of Italy?
Certainly, the Lombardy regional administration, like other regions in northern Italy, bears great responsibility for the dismantling of health and welfare due to its being administered for decades now by parties of the center right (Berlusconi’s Forza Italia) and extreme right (the Lega Nord and now simply Lega), all starting from 1995, year of the first mandate of Roberto Formigoni as regional Governor. In the early part of Formigoni’s governorship, in 1997, thanks to a law that had as its inspiring principle the funnelling of money into the private health sector, aimed at creating parity between the two sectors, the private sector forced its way into the regional health service, which is financed and supported by public money, and has reserved for itself the more profitable sectors of health assistance. Thus, with a minimum effort and cost it had ensured for itself maximum profits. The private sector, for example, take for themselves long term care facilities and leave to the public sector the management of less profitable sectors such as ER, or other sectors that are very costly such as psychiatry. In this competition, the public sectors witnessed the cutting of thousands of hospital beds with a constant depletion both in material resources and in human ones. Regional inspections of qualified structures are reduced, many services are subcontracted. There are situations where doctors working in the public facilities render services as private practitioners while using the public facility and machinery, as a way of reducing waiting lists (all of this happening under the Formigoni management). At the same time, strategic positions within the regional public health machine are assigned on the basis of political cronyism. These choices are ideologically based and have manifested with the destruction of the network of public drop-in clinics, and have materialized also in other sectors of life (an example of this, is the massive financing of families who chose private schools). The margin of freedom of action for these types of management from right wing parties was ensured to them by a large section of the center left parties, under the form of power sharing and backroom deals. Now the Covid-19 emergency is certainly not profitable for the private facilities. For example, it is not profitable to convert a clinic in which costly surgeries are performed, or that charge exorbitant prices for private rooms, into a Covid-19 facility. And this leads to the problem of having less control over situations, data, personnel safety because a management that is not public allows for less accountability, for more things to be swept under the rug. Now we know that the clusters that were hidden inside of private facilities were a vector for contagion, as were those in convalescent homes. We are left to wonder whether a national health system still exists. It seems that in this situation every region decides by itself who they want to help, whether or not they want to deploy health personnel to areas that are especially exposed. Perhaps it would have been important for a common policy to be developed at least the northern regions of Lombardy, Veneto, Piemonte and Emilia Romagna. Perhaps the national government could have, and should have, been vigilant in order to prevent this regional autonomy in managing healthcare from becoming an obstacle to the care of patients.
5) How have things changed in the city of Brescia overall?
In Brescia and in our province, everything changed radically, and the same has occurred in the whole country, even for those who, because they live far away from the contagion area, feel an indefinite sense of fear (which they do not really deeply believe in) rather than a sense of responsibility. Social interaction have completely disappeared and have been rerouted towards social media. People work and study at home (with all the implication which I will then try to analyze), going grocery shopping or going to the pharmacy has become a problem, mostly for the most vulnerable subjects or those who are less aware. In addition, the containment measures deriving from the ordinances limiting outdoor activities, which are constantly being changed, are not always easy and clear to interpret. But what I would like to underscore in relation to health personnel or people belonging to at-risk categories because of their daily contacts with patients, is that they have been left alone in managing their own self isolation inside their families (this is because monitoring and testing has been denied in spite of the constant request made by workers and unions). Furthermore, the production of non-essential good was never really halted in the province of Brescia or Bergamo. The wishes of Confindustria (the Confederation of Industry Owners) and its pressure on both the regional and central governments, which are rather sensitive to the issue pf profit, have expanded the number of activities that are deemed to be essential. Thus, workers continue to go to the factories and those who are kept apart on the production line (where the PPE are insufficient and recycled over many days!) then congregate in the locker rooms or in the cafeterias. Obviously, these same people then go back to their families becoming thus a vector for infection. A lot has changed also for senior citizens, who are, on one hand, hyper protected and, on the other, left out of the process. They are forced to give up their daily habits, can’t go out in the open air, cannot receive visits and yet they are forced to live in the same apartments with their family members who are workers and are potential vectors of infection.
6 ) Please give us a picture of your daily life during the lockdown. We have seen footage of the military convoys taking away the dead from Bergamo to other cities for cremation. What impact has that had on the local population and nationally?
Days follow one another other both rapidly and very slowly in this surreal atmosphere. Leaving aside waiting in line for the groceries or waiting outside the pharmacy, these two being the only opportunities to go out besides going to work, I would like to concentrate on analyzing the psychological situation in depth. Personally, I feel like I am in one of those suspended periods we experience during the lengthy illness of a loved one. Our energies are all there and can be recalled into action immediately. We are alert inside the situation, we can’t stay away from them, we try to take care of them, try to alleviate what can be alleviated, dream that they will heal, try to strengthen one another. But now, we have less external support, lead a solitary life, have very few distractions, are unable to even go out for a breath of fresh air or enjoy the comforting and reassuring presence of Nature around us.
We should, then, give some thought about how the capitalist model, founded on consumption of goods and people, has promoted the stigmatization of a slower, more solitary way of life, which is surely physically more tiring but closer to the deeper nature of humankind. Could this type of lifestyle, consciously chosen by some now, be considered a resource and a sort of shelter? I think that fear is an emotion tied to danger, whereas anxiety and anguish, both being widespread feelings these days, derive from a feeling of powerlessness in the face of mistakes, contradictions and deficiencies of this system. Paradoxically, this is a system which here in Italy is deemed to be a model, but on the contrary, actually exposes people even to more danger. Rage feeds on anguish, rage over something that is profoundly unjust like the wicked choices made in the past or like the manipulated information we are surrounded by now, consensus building lies that have always been there.
One of the most serious mistakes we made here in Italy, I think, was not testing the population at risk of contagion, i.e. the failure to immediately and systematically separate positive cases from negative ones. The repercussions were: 1) overcrowding of ER first and then ICU wards later (resulting in the attempt to dissuade those with mild symptoms from seeking hospitalization, but then having no way of staving off their conditions from rapidly deteriorating and needing hospitalization or sometimes dying at home having received no care). 2) Leaving the local neighborhoods uncovered due to the impossibility or refusal on the part of family doctors to visit the sick at home and assess their condition (In Italy, family doctors over the years have been forced to become bureaucrats rather than clinicians). In addition, the neighborhoods were left uncovered because of the transfer of medical personnel from neighborhood clinics to the isolation wards (a 70% to 80% reduction of forces in home assistance with patients who were not tested nor adequately cared for, nor were they put in a condition to follow correctly their isolation- this translated into devastating deaths for many families; late hospitalizations of patients who were never tested, but were put into isolation in the last days of their lives, without the presence of a relative with whom they could share fear and pain as well as memories and affection.
Those who lose or have lost someone are forced to experience a surplus of sorrow, a sorrow that cannot be processed and that is long lasting. Often the conditions of those who have contracted the virus worsen suddenly and then hospitalization is too late; we say goodbye and possibly may not ever see each other again. A casket is all that is returned to the families… a casket, which will be taken miles away to be cremated and the family will have two wait days and months for the cremation procedure to be performed so that they can finally mourn the dead.
I believe that being forced to experience such a brutal end-of-life process will leave serious psychological repercussions, both at a personal and at a collective level.
7) Can you please address your concerns about social distancing, mental health, and the social and political implications?
Personally, I also spend a lot of time thinking about the possible implications of emergencies deriving from this situation.
I am afraid that our fear of social contact, something we are learning now, will be a long lasting phenomenon. This is what I think in general. Specifically, I would like to address some aspects concerning mental health.
In a culture where mental illness is already normally misunderstood and subject to stigma, a distorted perception of these disorders could have serious effects, due to the extreme nature of our current situation.
In addition, people suffering from anxiety or mood disorders, depression, alcohol and substance abuse, those who had just started an individual or group form of therapy, will face a lot of problems continuing on their path or undertaking it because of the lockdown and the reduction of services.
Many doctors are sounding the alarm about a potential increase in suicide attempts in the future as well as an increase in psychotic episodes, signaling the emergence of forms of illness that had been latent up to now. An early sign of how fast we are losing control over the situation is the spike in involuntary psychiatric treatments we are experiencing now.
Another element to take into account is therapists and psychiatrists operating in the private sector who are forced to close down their offices or reduce their services, resulting in patients having trouble continuing their therapy (besides the threat on patients’ livelihood that impacts their ability to pay for services). I
There has been a great increase in alcohol consumption and the closing down of self-help and drop-in centers.
In the psychiatric wards there are additional critical problems stemming from a rigid observance of the prohibition to have direct contact with parents and friends, especially in the case of young and teen patients. I question what kind of thinking is behind these rules, whether any thought is given to prevention and overall care plan. I perceive great pain and disorientation on the part of the families of these patients, many of them dealing with psychiatric patients in their home during lockdown as well, as in the personnel working in psychiatric wars.
I am just suggesting that further thought be given to containment practices and the parties involved.
I would like to add that containment practices limiting the abillity to go out and move around, which were certainly necessary in general, will certainly not be helpful in family dynamics, especially where the family was already compromised by negative relations of power (by men over their female partners or by adults over minors). I have never stopped considering these aspects with concern and anguish, since the beginning of this epidemic.
I’m also thinking about the use of remote working, which in Italy is much more common among female workers, for example in the teaching professions I hope that this alternative mode of working will not become engrained in the future as the norm, or even be supported by employers the regular work practices (the risk is always there, even for remote schooling and distance learning).
These are only a few of the potential repercussions on social life, our social relations, our mental health and our relations with ourselves.
That’s why, in my opinion, these other potential effects had to be taken into account immediately, in order to avoid facing serious social and political emergencies down the line.
8) What do you think we need to do in terms of not leaving people behind, especially at a time when the national government is resorting to a “we are all in the same boat” discourse and is spreading a lexicon related to war rather than to public health?
This answer is in some way related to my previous considerations. Using a widespread lexicon of military and war reveals the firm determination to convince the public to identify an external enemy as the cause of this emergency. That is clearly functional to unloading the responsibilities upon others rather than face them, assign elsewhere the responsibility for the failures and the damage perpetrated by this criminal system. In the case of Italy, the finger should be pointed to that idea and practices of regional autonomy that has survived for decades in the secession-minded right wing parties, and now is manifested in souverainist thinking and fascism, with the complicity of the powers of the central government. On the subject of regional autonomy, I would like to add that in this region we were particularly affected by environmental pollution. The land here was turned into a desert due to its overconsumption and development stemming from the wicked choices made by so many political parties. I would say that, if you want to interpret the facts, these are times of unmasking! During a war, it seems perhaps that we’re all equally on the same boat. But that’s really not the way it is. In these times of emergency, faced with these responsibilities, social injustices become more acute. There are those who cannot get healthcare, those who don’t have money to hire caregivers, those who do not have enough space in their apartment, those who have precarious jobs, those who are alone and will suffer greater damages. Nobody’s equal today, and neither will they be tomorrow. The issue of war is also strongly connected to the theme of security, of defense. The undeniable sense of responsibility, whether personal or collective, implied in the containment measures, is instead an alibi to unload on citizens any responsibilities for their failings or success. The public is called on to choose either life or safety (and little by little safety here will be guaranteed at the borders of towns, by the checkpoints, in addition to the police and the army, and by some good “cooperating” citizens). I would conclude quoting from one of my writings, “Having to choose between life or freedom is false choice. Because the two concepts, both in theory and in practice, depend on an analysis of the current situation built on a past that has not given them much thought nor has been a steward of the two concepts. I think that the processing of grief, losses but also changes are built “today” need to be done while “inside the emergency” and not “afterwards” as we are often being called to do. These processes need to be undertaken with collective critical thought. That is, Reconstruction of the ‘aftermath’ depends on the way we face an emergency today. The worst mistake is to think about the emergency and the aftermath as two separate, closed off boxes. We must really be on the lookout: an emergency faced without critical thinking will also result in ongoing and sustained political, social and psychiatric emergencies.
Valeria Raimondi is a poet, nurse and social activist. Her poetry collections include IO NO (Ex-io), Thauma ed., 2011 and the award winning Debito il tempo, Fusibilia ed., 2014. She is the editor of an acclaimed anthology of Italian poetry dealing with labor in the 20th and 21st century, La nostra classe sepolta, Pietre vive editore, 2018.
Cover art: “Sun Flares”, collage by Vicky Helms.